Name: Girls Inc. Membership
SKU: 10568
Availability: InStock

Participant's Information
Girl's Name*
First Last
Phone
Girl's Email
Girl's Address*
Street Address Address Line 2 City State ZIP Code
Township
Current School*
Birthdate*
Grade
Racial/Ethnic Group*
This information helps us report information about our girls to donors and grant funders.
Girl's Primary Language

Household Information
Primary Caregiver's Name*
First Last
Cell Phone*
Email*
Other Caregiver's Name
First Last
Cell Phone
Email
Yearly Gross Family Income*
This information helps us report information about our girls to donors and grant funders.
Eligible for Free/Reduced Lunch*
- Yes
- No
Eligible for TANF*
- Yes
- No
I/We Will Receive Text Messages*
This option will allow Girls Inc. to send messages about field trips and or schedule changes to you immediately. We will not send advertising messages in text.
- Yes
- No
Girl lives with*
Number of Family Members Living in Household*

Safety
Emergency Contact*
Please list an individual other than the primary caregiver.
First Last
Emergency Contact's Relation to Girl*
Emergency Contact's Phone*
The following people may pick up my girl*
Please list all possibilities. Individuals not on this list will not be able to pick up your girl without advanced notice.
Is there anyone who should NEVER pick up your girl?*
- Yes
- No
Individuals who may NEVER pick up my girl
My girl is allowed to leave the premises on her own*
- Yes
- No
Please explain instances when your girl may leave on her own.

Medical Information
Physician's Name*
First Last
Physician's Phone*
My girl is allergic to
Please list all allergies including food and medications.
My girl takes this medication
My girl has the following special health needs
In Case of Emergency*
I give my permission for Girls Inc. staff to secure emergency medical and non-surgical care for my minor child while participating in approved Girls Inc. activities. I also give my permission to have my child transported to the nearest emergency care facility and for hospital/emergency staff to begin any necessary procedures.
- Yes
- No
Photo/Video and Social Media*
I consent to and authorize Girls Inc., or anyone authorized by Girls Inc.,to use all photographs and video of me and/or my child during this membership year (one year from this date) for any purpose, including publication, display, and exhibition in promotion without compensation to my child or me. I agree that the photographs shall constitute your sole property, with full right of disposition in any matter whatsoever. I hearby release and discharge you from any and all claims whatsoever in connection with the use of these photographs and the reproduction thereof. I understand Girls Inc. only uses first names for identification as a matter of protection and does not sell or release photos to anyone outside the organization.
- Yes
- No

Membership Registration
Signature of Primary Caregiver*
I verify that I am the legal guardian of this girl. I have read the foregoing and understand its contents. I agree to read the Girls Inc. handbook available online at https://girlsinc-monroe.org/programs/membership/
Girls Inc. Membership*
Price: $55.00

Girls Inc. Membership

Participant's Information